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Please cite this article in press as: Bierens JJLM, Warner DS. Drowning resuscitation requires another state of mind. Resuscitation (2013),

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Contents lists available at ScienceDirect

Resuscitation

journal homepage: www.elsevier .com/ locate / resusci tat ion

Editorial

Drowning resuscitation requires another state ofmind

This issue of resuscitation includes a large prognostic Utstein-

based drowning resuscitation study from Osaka, Japan, which at

first glance reports very disappointing outcomes. Of the 1737

drowning victims who were in a cardiac arrest at arrival of emer-

gency medical services (EMS), only 0.8% were alive with normal

neurological function after one month.1 The study is consistent

with another Japanese cohort study,2 but contrasts with casereports where more optimistic outcomes have been reported.3,4

A conclusion of the current publication could be that resuscitation

of drowning victims is useless and that we should perhaps return

to the 17th century when the laws in many European countries

required that drowning victims remain untouched with at least

their feet hanging in the water so as to allow police to determine

the cause of death.5

Theworkof Nitta etal.1 emphasisestherealityof thedown-side

of resuscitation efforts and the importance of effective drowning

prevention strategies.68 At the same time, the study allows us to

learnmoreaboutsomekeyelementsof drowningresuscitationand

drowning resuscitation research.

Indrowningvictims, importantpredictors forsurvival arewater

temperature,3,9

submersion time,9,10

adequacy of bystander car-diopulmonary resuscitation (CPR),2,11 andEMS response time.12,13

Nitta et al.1 correctly mention that their study has been based on

Utstein template of data collection for cardiac arrest,14 andnot on

theUtstein template for drowning.15 Their study, therefore, could

notprovidedataon thesepredictors invaluabledetail. Thereported

average EMS response timeof 7min however provides an estimate

of the out-of-water anoxic interval. The total (under-water plus

out-of-water) anoxic intervalmusthavebeensubstantial. Notably,

almost 60% of the victims did not receive any bystander CPR and

an additional 20% received compression-only CPR. Also the time

to install the automated external defibrillator (AED), ultimately

superfluous as reported inmany drowning studies,2,12,13,16,17may

have to be added to the total anoxic period. Taking these factors

into account, it is not surprising that the EMS providers could not

achieve restoration of spontaneous circulation (ROSC) in 84% of

overall study population.1 It is a reasonable finding that severe

anoxic brain damageoccurred inmany of the remaining victims.

Nitta et al.1 do provide important newdata regarding effects of

victimageon resuscitation success. ROSC wasrestored by theEMS

in 53% (19/36) of 04 year old children, in 28% (9/32) of 517 year

olds. This markedly contrasts with a rate of 12.5% (208/1669) in

those older than 17 years. Interestingly, this study does not iden-

tify any patient in which ROSC was achieved after arrival in the

hospital.4,13,18,19 For those in whom ROSC was achieved, survival

after 1 month in 04 year oldswas 53% (10/19), 33% (3/9) in 517

year olds, and14% (28/208) in those>17years ofage. Thefrequency

of neurologically intact survival, assessed at 1 month, showed an

oppositeage-related trend:20% (2/10)of 04 year olds, 33%(1/3) of

517 year olds and39%(11/208)of thoseabove17yearsofage. This

doesnot necessarilypredict long-termfunctionalrecovery. Several

casereportsofdrowningresuscitationhaveobservedimprovement

ofneurological functionafterthefirstpost-resuscitationmonthasaresultofneuro-rehabilitation.20,21Ontheotherhand,moredetailed

neurological andneurophysiological investigationsaftermonthsor

years show complications that had before gone unnoticed.6,22

A further remark needs to be made. This regards the com-

plex relationship between outcome, drowning mechanisms, and

drowning populations.23 Notably the large number of elderly vic-

tims included in the Nitta el al.1 study population (mean age 77

years; interquartile range 6784) is remarkable and indicates fur-

ther investigation of the drowning mechanisms.24 It may be that

particular mechanisms or populations have a poorer prognosisper

se.

Taking these factors in to consideration, let us go back to the

physiologyof drowning and again lookat the dataofNitta et al.1 to

better understandwhytheoutcome in their studywasso tragicallylow.

First, it is essential to understand that cardiac arrest in drown-

ing is not like the onoff physiological mechanism occurring in

most out-of-hospital cardiac arrests (OHCA). In drowning, cardiac

function gradually deteriorates over several minutes as a result of

progressive hypoxia. Drowning physiology implicates that early

ventilation and oxygenation are essential for survival. It is also

known that airway resistance maybe extremely high in drowning

victims. This can prevent effective ventilation in the pre-hospital

setting and during transportation.4,25,26 In other situations, where

rescue and resuscitation have been performed by the same per-

son, extremely large tidal volumes are often inflated which result

in outflow limitations of the right ventricle and lower perfusion

pressures during cardiac compressions.27,28 The ventilatory com-

ponent of treatment is not only relevant during resuscitation but

also during in-hospital treatment. A number of drowning victims

will dieduring thefirstweek asa resultof adult respiratorydistress

syndrome and pneumonia.29 These respiratory aspects may have

contributed to the high number of patients who died in hospital

after ROSC.

Children are an important proportion of drowning vic-

tims. Bystanders, EMS and physicians are less competent in

airway management in children.30,31 Previous studies have

expressed concerns that regional differences in paediatric OHCA

in Japan may be attributed to an EMS system that is yet

0300-9572/$ see front matter 2013 Published by Elsevier Ireland Ltd.


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27. Aufderheide TP, Sigurdsson G, Pirrallo RG, et al. Hyperventilation-induced hypotension during cardiopulmonary resuscitation. Circulation2004;109:19605.

28. Barcala-FurelosR, Abelairas-GomezC, Romo-PerezV, Palacios-AguilarJ. Effectofphysicalfatigueon thequalityCPR:a waterrescue studyof lifeguards:physicalfatigue and quality CPR in a water rescue. AmJ Emerg Med 2013;31:4737.

29. van BerkelM, Bierens JJ,Lie RL,et al.Pulmonary oedema, pneumonia andmor-tality in submersion victims; a retrospective study in 125patients. IntensCareMed 1996;22:1017.

30. Gerritse BM, Draaisma JM, Schalkwijk A, vanGrunsvenPM, Scheffer GJ. ShouldEMS-paramedics performpaediatric trachealintubation in thefield? Resuscita-

tion 2008;79:2259.31. Lammers R, Byrwa M, FalesW. Root causesof errorsin a simulatedprehospital

pediatricemergency. AcadEmerg Med2012;19:3747.32. Okamoto Y, Iwami T, Kitamura T, et al. Regional variation in survival following

pediatricout-of-hospital cardiac arrest. Circ J 2013.33. RoYS, ShinSD,SongKJ, etal. Acomparisonof outcomesof out-of-hospitalcardiac

arrest with non-cardiac etiology between emergency departments with low-andhigh-resuscitationcasevolume. Resuscitation 2012;83:85561.

34. TopjianAA, Berg RA, Bierens JJ,et al.Brain resuscitation in thedrowning victim.Neurocrit Care 2012.

35. Handley AJ. Compression-only CPR-to teach or not to teach? Resuscitation2009;80:7524.

36. Kochanek PM, Bayir H. Optimizing oxygenation and ventilation after cardiacarrest in little adults. Resuscitation 2012;83:14256.

Joost J.L.M. Bierens (MD, PhD) Q

Maatschappij tot Redding van Drenkelingen (Society

to Rescue People from Drowning), Rokin 114 B, 1012

LB Amsterdam, The Netherlands

David S.Warner (M.D)

Department of Anesthesiology, Duke UniversityMedical Center, Durham, NC 27710, USA

Corresponding author. Fax: +1 9196846692.

E-mail addresses:[email protected] (J.J.L.M.

Bierens), [email protected] (D.S.Warner)

3 September 2013

Available online xxx

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